Basic Information
| Provider Information | |||||||||
| NPI: | 1518968155 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MILLER | ||||||||
| FirstName: | OTIS | ||||||||
| MiddleName: | E | ||||||||
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| NameSuffix: | II | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 411039 | ||||||||
| Address2: | |||||||||
| City: | KANSAS CITY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 641411039 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9132341350 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 9100 W 74TH ST | ||||||||
| Address2: | |||||||||
| City: | SHAWNEE MISSION | ||||||||
| State: | KS | ||||||||
| PostalCode: | 662044004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9136762214 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/04/2005 | ||||||||
| LastUpdateDate: | 06/30/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/30/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 04-28117 | KS | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 26047069 | 01 | MO | BCBS OF KC MO | OTHER | P00183119 | 01 | RR MEDICARE GROUP DC6712 | OTHER | 01674018 | 01 | BCBS KCMO GROUP 01674018 | OTHER | 26047049 | 01 | KS | BCBS KC MO | OTHER | 100345990C | 05 | KS | MEDICAID | 206039505 | 05 | MO | MEDICAID | 100345990A | 05 | KS | MEDICAID | 930128507 | 01 | RR MEDICARE GROUP CC8899 | OTHER |